Nurse Practitioner Palliative Aged Care (NP PAC) Case Study

Navigating A New Area Of Care and
Developing a Focussed, Achi...
The Australian Nursing and Midwifery
Accreditation Council (ANMAC)
defines NP practice as:
'A nurse practitioner is a regi...
Context:
Cancer – person remains fairly well and then experiences a rapid
decline – Often need Specialist Palliative Care ...
Ruby:
Ruby was a 92 year old woman with
advanced dementia, living in
residential aged care. She had been
non verbal, heavi...
Comorbidity

Comorbidity of 10 common conditions among UK primary care patients2
BMJ 2012;345:e6341 doi: 10.1136/bmj.e6341...
My Dad
88 years old – first diagnosed with Ischemic Heart Disease at aged 68 resulting in 6 CABG’s - further 3
CABG’s 4 ye...
My Vision
• To empower nurses in reclaiming natural dying as a core nursing
priority not a medical condition. Liken to Mid...
Getting Started:
What would the role look like?
Where did the role fit:
- within HNE health?
- within the community / regi...
Scope of Practice:

Advanced
Practice
Familiar Task

Unfamiliar task:
• Advance Care Planning – preparing for a time
of re...
Defining Boundaries of Practice
•
•
•
•
•
•

Across two key specialities: Palliative and Geriatric medicine
Across Sectors...
Reality Check
• Massive gap in service – one person
• Largest LHD in NSW
• Identified broad skill set of NP:
–
–
–
–
–
–

...
Centre for Healthcare Redesign
HNELHD Palliative Aged Care Nurse Practitioner (PAC) Project

Two colleagues also with a st...
Summary of Key Issues
•

•

•
•

90% of audit
population identified
as ‘death not
unexpected’
< 30% had EOL
discussion
doc...
Implementation of solutions to support MoC

Shared Care - Nurse Practitioner Palliative Aged Care, SPC and GPs
A Collaborative Approach
‘Informed’ and shared decision making requires a
supportive multidisciplinary, collaborative appr...
Advance Care Planning Journey
Signed
Medical Order re:
treatment preferences

Prognostication
Disease Trajectory

Person C...
The circle of life

Thank you
Jacqueline Culver,Hunter New England Health District: Navigating A New Area Of Care And Developing  Focussed And Achievabl...
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Jacqueline Culver,Hunter New England Health District: Navigating A New Area Of Care And Developing Focussed And Achievable Scope Of Practice

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Jacqueline Culver, Nurse Practitioner Palliative Aged Care, Hunter New England Local Health District delivered this presentation at the 2013 Developing the Role of the Nurse Practitioner conference. The event is designed for organisations and managers looking to better understand, utilise and grow the role of the nurse practitioner in their health service. For more information about the annual event, please visit the conference website: http://www.healthcareconferences.com.au/nursepractitionersconference

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Jacqueline Culver,Hunter New England Health District: Navigating A New Area Of Care And Developing Focussed And Achievable Scope Of Practice

  1. 1. Nurse Practitioner Palliative Aged Care (NP PAC) Case Study Navigating A New Area Of Care and Developing a Focussed, Achievable Scope Of Practice Jacqui Culver NP M.(Nurs.Prac);R.N.;RSCN.:B.Ed.;Dip.Couns.:Dip.F.L.Mgt;;TAA04
  2. 2. The Australian Nursing and Midwifery Accreditation Council (ANMAC) defines NP practice as: 'A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession's values, knowledge, theories and practise and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context of practice.‘ ……………………. the theory
  3. 3. Context: Cancer – person remains fairly well and then experiences a rapid decline – Often need Specialist Palliative Care for intense symptom management at end of life due to complexity. Chronic Disease / Organ System Failure – person has periods of wellness with acute exacerbations when death may or may not occur – becoming more frequent towards end of life. The PAC NP, as a member of the primary health care team can coordinate end of life planning and care, referring to Specialist Palliative Care professionals if needed. Dementia / Frailty – person has a very slow decline and a gradual shutting down of body and body systems. This can lead to a longer terminal phase as natural dying occurs through dehydration and multi organ / system failure. End of Life can be well supported within a primary health care model which includes the PAC NP .
  4. 4. Ruby: Ruby was a 92 year old woman with advanced dementia, living in residential aged care. She had been non verbal, heavily dependant for all ADL’s and doubly incontinent for well over12 months. Her daughter noted a decline in mobility and in swallowing capacity and decided bring Ruby home to die within her own home. Ruby lived on for a further three months and with advanced care planning died peacefully in her own home with her multi generational family all around her. Not one patient but many
  5. 5. Comorbidity Comorbidity of 10 common conditions among UK primary care patients2 BMJ 2012;345:e6341 doi: 10.1136/bmj.e6341 (Published 4 October 2012)
  6. 6. My Dad 88 years old – first diagnosed with Ischemic Heart Disease at aged 68 resulting in 6 CABG’s - further 3 CABG’s 4 years ago other wise fit and well until 12 months ago when he collapsed on the golf course. Family history of Heart Disease: Father died of Heart Attack at 64 and Mother died of CHF at 70 Current Comorbidities: Ischemic Heart Disease Carotid Artery Disease Right Heart Failure Interstitial Pulmonary Fibrosis Pulmonary Hypertension Atrial Fibrillation / Arrhythmia’s Syncope: Postural Hypotension Cognitive impairment > Hypoxia Chronic renal impairment Medications: Metoprolol Perindopril Digoxin Frusemide Spironolactone Omeprazole Warfarin Vitamin D Specialists: Cardiologist Pulmonary General Med Vascular Geriatrician
  7. 7. My Vision • To empower nurses in reclaiming natural dying as a core nursing priority not a medical condition. Liken to Midwifery . . . . . . • To support elderly frail people and /or their loved ones, in making informed quality of life (QOL) decisions about treatment options as they approach the end of life. • To have frailty and chronic comorbidity recognised as a complex and unique speciality in its own right. • To change the world – or at least my corner of it
  8. 8. Getting Started: What would the role look like? Where did the role fit: - within HNE health? - within the community / region? - alongside existing services? Was this primary care at a tertiary level or tertiary care at a primary level?? What did we want to achieve, what was possible to achieve and where could we make the most impact on improved patient care, whilst ensuring future sustainability within HNELHD?
  9. 9. Scope of Practice: Advanced Practice Familiar Task Unfamiliar task: • Advance Care Planning – preparing for a time of reduced wellness, capacity and death. • Clinical reasoning ++ Juggling symptoms • Supporting ‘Dignity of Risk’, ‘Quality of Life’ ‘Self Determination’ and ‘Natural Dying’ Unfamiliar environment Nurse Practitioner Capability Nurse Specialist / consultant Competency Advanced Practice Registered Nurse Familiar environment Reference unknown Unfamiliar Task Unfamiliar environment: • Complex comorbidity – chronic disease >multi system failure, >longevity > frailty • > dementia and chronic illness – greater dependency, greater expectations, knowledge • ‘Silo’ – specialities – including ‘specialist’ palliative care – ‘referral’ commonplace • ‘Ageing in place’ v Community living/dying
  10. 10. Defining Boundaries of Practice • • • • • • Across two key specialities: Palliative and Geriatric medicine Across Sectors: HNE Health – Community NGO’s Across funding bodies: State and Commonwealth Across health providers: Acute, Private, Community, RACF’s Transitional process: from a curative to a palliative approach Multi speciality: cardiology, respiratory, vascular, renal, rheumatology, neurology, oncology, psychogeriatric, general medicine, endocrinology . . . . . . . . . . . . . . • Highly vulnerable clientele with reduced capacity to self manage health care and living within complex family systems. • Ethical Issues: Poly-pharmacy, Futility of Treatment, Silo mentality
  11. 11. Reality Check • Massive gap in service – one person • Largest LHD in NSW • Identified broad skill set of NP: – – – – – – Geriatric and Palliative Clinical Assessment End of Life care and symptom management Advanced Dementia Management Advance Care Planning Discussion Education and Training – Capacity Building Strong background in Aged Care Services
  12. 12. Centre for Healthcare Redesign HNELHD Palliative Aged Care Nurse Practitioner (PAC) Project Two colleagues also with a strong interest in this area applied for NSW health funding for training in clinical redesign. They adopted the NP PAC as their redesign project: Lisa Shaw - ACP Coordinator Mandy Harden - CNC Aged Care Project Aim: To develop a Model of Care for a Nurse Practitioner in Palliative Aged Care.
  13. 13. Summary of Key Issues • • • • 90% of audit population identified as ‘death not unexpected’ < 30% had EOL discussion documented in medical record Prognostication difficult for chronic disease and frail aged clients No plans for expected health deterioration / EOL • • 70% of audit population had ACCR in place 25% of audit population transferred to hospital from RACF and died in hospital Av LOS in final admission 3 days for 50% of Audit population 25% of audit population had LOS 11-57 days • Poor health literacy for client/family • • • • Audit population used average of 5 community services in last year of life No central record / communication process Multiple service providers with inconsistent care co-ordination Limited understanding of shared decision making process • • Range from 1-5 hospital admissions in final year of life Range from 1-8 ED presentations in final year of life Average of 7 comorbidities Dementia 3 x more common then any other chronic disease Limited understanding of SDM role
  14. 14. Implementation of solutions to support MoC Shared Care - Nurse Practitioner Palliative Aged Care, SPC and GPs
  15. 15. A Collaborative Approach ‘Informed’ and shared decision making requires a supportive multidisciplinary, collaborative approach. Person / Person Responsible and other family members Any discussion should be focused on realistic treatment and care options that provide quality of life outcomes, for the person experiencing the latter stages of their disease trajectory. Some topics that may be covered in an ACP discussion. Person, Family & Care Team • Potential issues – i.e. Pain • Futility of treatment • Medication review • Place of care at the end of life Doctor, Geriatrician Nurse Practitioner Nursing, Allied Health and Care Staff Person Centred Care • Environmental aspects • Family involvement Nurse Practitioner - Shared Care Model The PAC NP aims to work with the persons GP in shared care, so that any aspect of care and treatment that falls outside the PAC NP’s scope of practice can be referred back to the GP for monitoring or treatment.
  16. 16. Advance Care Planning Journey Signed Medical Order re: treatment preferences Prognostication Disease Trajectory Person Centred Care Shared Decision Making & Advance Care Planning documented Person, Family & Care Team Information about Legal & Ethical, Planning ahead What to expect Discussion Case Conference Person / Person Responsible / Family Multidisciplinary Team GP/Medical Officer /NP Nursing & Care Staff
  17. 17. The circle of life Thank you

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